Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Wednesday, November 26, 2014

In case you don't know what the Cochrane Collaborative is, it's an organization that compiles systematic reviews of medical interventions, conducted according to rigorous standards. There's a new one on interventions to improve medication adherence, and it isn't pretty.

A commonly bandied about round number is that about half of prescribed medication doses aren't taken. Of course the number varies according to the kind of medication and the circumstances, but there's no denying that people often don't take their pills as prescribed. Sometimes this matters a lot, sometimes a little, but even people with a lot to lose -- such as people with HIV, or glaucoma -- don't all take their medications regularly.

Well, the Cochrane reviewers looked at 182 randomized controlled trials and found only 7 high quality trials that showed any beneficial effect on medical outcomes and even those were pretty small. And the interventions were complex and expensive, pretty close to having a nurse move in with you. I've spent years trying to figure out why this is. There are a lot of different reasons but here are a few of the most important.

1) If I take the pills, that means I have the disease. And I don't want to have the disease. This would seem to reverse cause and effect but it doesn't really. There are two meanings of "having the disease": The doctor's meaning, which is a biological construct; and the patient's meaning, which is a psychosocial construct.

2) There are other things in life that are higher priorities. Swallowing pills isn't particularly hard, but constantly dealing with refills can be a hassle, co-pays matter to many people, and it's easier just to convince yourself that it isn't really necessary.

3) The person doesn't believe the doctor's theory about what's good for him or her. Not extremely common but totally dispositive when it happens. The many well-publicized instances of drug company malfeasance make this actually not entirely ridiculous. Sometimes it's even true.

Tuesday, November 25, 2014

No, the post is not about YT. I'll get to it in a moment. In passing, I don't really have anything to add about current events except that it is obviously the case that cops in the U.S. have a license to murder Black men. No possible circumstance would seem to result in prosecution.

That out of the way, I'm working on a paper now about people living with HIV. I intended to find out how much biomedical understanding they had of the virus, its pathophysiology, and treatment, but all that turned out not to matter very much to them. When I asked people, "If you had to explain to somebody what HIV is, what did you say," I'd get a lot of answers about how it is transmitted. Other responses included "It means I made a mistake," "It's not a death sentence," "It's a disease like any other, you can learn to live with it," and so on.

For most people, it took a while after they got the diagnosis for them to incorporate the new reality into their self-concept. A few people never did. Some had very negative reactions at first: attempting suicide, drinking heavily. But eventually, they sorted into people who turned it into group A -- People who responded posivitely; they felt good because they were taking care of themselves, being a role model for young people, had grown in wisdom and goodness through the contemplation of their mortality: and Group B: they remained in guilt, or anger, or despair. And it was the latter group who were less likely to be taking the pills on regularly and on schedule.

It isn't very deep wisdom that we need to make lemonade out of life's lemons, I suppose. But I wonder how well aware physicians are of this very basic truth about illness and self-care. What we need is the magic pixie dust we can throw on the people and transform them into the overcomers.

The only conceivable national interest the United States has in who governs Afghanistan is the illicit opium industry. And our $760 billion has not been well spent in that regard, since opium production in Afghanistan is now at an all time high. The last time opium production was effectively stopped in Afghanistan was when the Taliban ruled, before the U.S. invaded.

So what exactly the hell are we doing there? For $10.17 million an hour, I want more than zero.

Friday, November 21, 2014

Everybody is talking about Cosby, so what do I have to add? Not much, so here's 2 cents.

Maybe this is weird or maybe it's typical, but I don't recall ever hearing about these allegations until this week. Evidently they were reported earlier in a couple of places, but all of a sudden got major attention, purportedly due to a routine by a little-known comic that did the viral thing. Whether this heralds a New World Information Order seems to be one of the questions of the day.

I don't know about that, but I do think the zeitgeist is changing. Like the cultural landslide that is burying homophobia, we are suddenly seeing a massive change in prevailing norms about sexual assault. (Struggling mightily to keep my metaphor unmixed) the boulders started rolling in the military, rolled onto college campuses, and now are knocking down the privileges of the famous and iconic.

Is it a reach to say that we are finally seeing more payoff from the long, slow but very real expansion of the number of women in influential roles? Female senators had a lot of to do with the focus on the military, as do female faculty and administrators in universities, and now women in the news and entertainment industries. That's not all the credit obviously -- lots of men are on the right side. But it helped to get us to this tipping point.

As for the question of Cosby's innocence until proven guilty, come on. There will never be a trial but we're allowed to use our common sense to draw reasonable inferences. At the same time, this has no bearing on the soundness of his Booker T. Washington politics, which continue to stand or fall on the merits; nor on the value of his cultural contributions. Wagner's music is what it is, regardless of his antisemitism, and Pablo Picasso is widely thought to have been an asshole. (That's the technical term.)

Still, going forward, no-one will be able to suspend disbelief in the Cosby persona or find him amusing. (He was already pretty much anachronistic anyway, so small loss.) When the reality of the actor behind the mask is that overpowering, the act is bound to fail. So he is now gone from public life, and he'll just wither away.

Wednesday, November 19, 2014

I'm appearing on a panel tonight at our great university, entitled "Doctors reading race: how conceptions of race shape medical care." Since you probably can't attend, here's the sneak preview.

When I first began to study this issue, 15 or 20 years ago, there were quite a few influential studies that identified disparities in physicians' treatment decisions based on patients' race or ethnicity. For example, Latino patients with long bone fractures were less likely to be prescribed opioids in emergency departments. Doctors were less likely to take a sexual history from adolescent white adolescent girls presenting with abdominal pain than from Black and Latino girls. Black veterans in VA hospitals who'd had myocardial infarctions were less likely to undergo revascularization. (Interestingly, they were also less likely to die. This led the authors to propose that "process of care is a more specific indicator of quality than is outcome. Ha ha.) There were others.

Back then we had all sorts of calls for "cultural competence" in health care, and people sprang up who offered cultural competency training, generally for a fee. In its earliest incarnation this mostly consisted of people who would proffer interesting tidbits from medical anthropology about exotic health beliefs. They'd tell you that Puerto Ricans believe in the Evil Eye and rural African Americans are into rootwork and mojo, that sort of thing. Absolutely ridiculous. It's like teaching doctors that patients from California believe in the healing power of crystals. Maybe a few of them do but that's not what you need to be culturally competent.

So then we got a better class of cultural competency trainers who claimed, more plausibly, that the first step toward becoming culturally competent is to have insight into your own culture. What are your preconceptions and how do you understand the nature and meaning of health and illness, and medical care? The next step is to learn how to not make assumptions about the people you encounter, but rather to learn from them. Ask them! What do you want to know? What are you comfortable and not comfortable telling me about yourself? How do you understand your condition and treatment? How do you want us to relate to each other? Everybody is unique, your job is to understand each person.

This all sounds great but I haven't seen any evidence that this sort of intervention produces better results or more satisfied patients, though I don't suppose it can hurt. So what have I found in my own research?

First of all, using my structured methods for analyzing clinical encounters, we've noticed a couple of things. Black patients, on average, talk less than Latino or white non-Hispanic patients, but there doctors talk just as much. This has been observed by others, in a couple of different settings. The result is that the so-called verbal dominance ratio -- the proportion of doctor to patient talk -- is higher for Black patients. Of course I have no idea why. There are also some other indications of less rapport or patient engagement, including fewer so-called expressive utterances by Black patients -- those are expressions of desires, goals, feelings, intentions -- and less joking with Latino patients. But again, I don't know why this happens or what significance it has.

What I have observed is that where things tend to go wrong is doctors not understanding patients' lifeworlds. The fact is that most medical encounters are essentially cross-cultural. Physicians tend to start off as higher socio-economic status than most patients before they get to medical school. Being a physician is, in fact, often a hereditary condition in itself. Then they go through a socialization process in which they internalize a particular way of understanding human beings and the nature of health and disease. Then they ultimately go on to live in pleasant neighborhoods and have nice things.

This makes it hard enough to understand the experience, perceptions and needs of the typical patient who comes before them; But more social distance, be it of class, ethnicity, language and culture, just compounds the problem. The physician may make stereotypical assumptions about people, and may make other assumptions based on assuming that the patient or the patient's situation is more similar to the physicians than the reality. I have many fascinating examples but I'm only supposed to talk for 10 minutes so maybe I'll get to some of them in the Q&A.

So I'll just leave off with this. When I worked for the New England Coalition for Health Equity, I'd go around to various meetings and conferences where one way or another the idea of cultural competency was promoted. I can't tell you how many times I heard doctors say, "I don't need any training, I don't have any issue with cultural competency. I treat everybody the same." I'll leave it to you to ponder if that's a good answer.

Sarno has a psychodynamic explanation. He thinks that suppressed anger is translated into low back pain. The linked essay by Todd Hargrove offers good arguments why that doesn't make sense. But I want to use this example as a jumping off point for a broader discussion.

It is very common for someone to get an idea that perhaps seems plausible (sometimes it does not, even superficially, viz homeopathy), and then become very attached to it. Sometimes these people have strong scientific credentials. Nobelist Linus Pauling, with his supposed discovery that large doses of vitamin C are a panacea, is an excellent example. These people may gain large followings. But .. .

There is no credible scientific evidence for the idea. The originator and his (or less often her) followers are convinced that it works, but we never get past anecdotes and testimonials. Many precincts of the Internet devote substantial resources to debunking such claims. I recommend Quackwatch, which has a lot of fun stuff to read, and Science Based Medicine, a blog by rotating authors that reliably puts up a new essay every day.

I won't trouble to repeat here the extensive resources you can get to via those links to understand how to recognize pseudo-science, and the harm it does. But I do want to talk briefly about the whole problem of motivated reasoning.

The originators of quackery probably actually believe in it, most of the time. They aren't consciously lying. But they do, of course, have a lot at stake: their self-image as breakthrough thinkers, the gratitude and loyalty of their devotees, quite likely money, reputation and fame. So their thinking becomes dedicated to strengthening the belief, and the whole world is seen through the lens of confirmation bias.

Unfortunately the whole world largely works this way. Social psychologists have found that showing true believers evidence that contradicts their beliefs just strengthens them. Sen. Inhofe says he was at first convinced by the argument that burning fossil fuels is changing the climate but then he found out how much it would cost to do something about it. So he changed his belief. Creationists don't want to give up the myth of original sin and redemption through the sacrifice of Christ, which makes no sense to begin with but they make their living from the collection plate or the TV ministry. I could go on.

So why am I so sure my own beliefs are generally correct and rational? I suppose I can't be entirely, but I am aware of the problems of confirmation bias and motivated reasoning so I make a serious effort to continually re-examine my ideas and to insist on standards of evidence for my understanding of the world. The evidence that I do this is that I have frequently changed my opinion about matters large and small.

I grew up going to church and Sunday school and believing in a high church protestant version of Christianity. Once I was old enough to think for myself, I concluded it was bunk. I was never a Communist but as a youth I read romanticized accounts of the Chinese revolution and I thought that on balance it was a good thing. I had no appreciation of the depravity of Maoist tyranny but I do now. At first I wasn't at all convinced that the official version of the 9/11 attacks was accurate but I sorted through the evidence and the arguments and ultimately concluded that it is, essentially. (I think it likely that the government has deliberately covered up involvement by Saudi royalty, for reasons of geopolitics. I also find it plausible that the Bush administration security establishment expected something of the kind to happen, without having specific information, and had no interest in preventing it. But that's only a suspicion, I certainly can't assert it.)

In my professional work, I used to think that average people could be empowered to have a mechanistic understanding of their health and treatments that more or less corresponded to the ways their doctors think but now I believe that is unrealistic for most people. What I am striving for now is to understand the nature of the information people really do need and can use to make good decisions on behalf of their own health and well-being, but I think it has a small component of science and a bigger component of other kinds of meanings.

I may well cling to some ideas due to confirmation bias, but I do recommend this exercise to you. Try to take an inventory of important ways in which you have changed your mind over the years. If you can't come up with very many, maybe you should undertake a critical assessment of one or more of your cherished beliefs and see what happens. Can you find reason to doubt? Make a serious effort to talk yourself out of what you think now. Go down that road and see where it leads. You might well decide you were right in the first place, but at least you will have put it to the test.

Monday, November 17, 2014

Krugman points out that contrary to Republican freakout, the Administration responded competently and effectively to the ebola outbreak, the Affordable Care Act is working just fine, the Department of Energy loan program that lost money on the Solyndra investment has in fact made an overall profit of $5 billion, and the deficit has in fact fallen sharply. In other words, government can indeed do things well.

Rattner is despairing, as economic inequality in the U.S. grows worse, and the incomes of people near the bottom are actually falling. But, it's worse here than it is in Europe. We have the lowest tax rates of the OECD countries, and the least generous social programs. Republicans constant screaming that our taxes are too high is just nonsense. And in fact, higher taxes are not associated with lower rates of growth. That's pretty simple: government spends that tax money, creating demand directly, and by giving people salaries that they in turn spend; meanwhile, wealthy people spend a much smaller portion of their income than do poor people. And they don't create jobs either. They won't invest in job creation unless they can sell stuff, and they can't do that if people don't have the money to buy it. Also, government makes essential investments that the private sector never will, because of the problems of free riders and common goods.

But the corporate media, not to mention Democratic politicians, don't seem to understand any of this. Republican claims that tax cuts stimulate the economy go unchallenged. Yes, the wrong kinds of taxes at the wrong time slow down the economy, but right now taxing the rich to invest in the present and the future would be good for economic growth, and particularly sustainable growth. Mass transit, basic research into renewable energy and conservation, creating a smart power grid, educating the children who will make our future, guaranteeing affordable health care for all -- these are all things government can and must be doing. And anybody who says otherwise is a lunatic. Of course, they can always move to Kansas.

Friday, November 14, 2014

I'm working up a couple of research proposals having to do with chronic pain. This subject is actually challenging clinically and philosophically, which means it also very challenging for physician-patient communication and relationships.

There used to be great controversy over the very existence of fibromyalgia, or the usefulness of the label. It just meant people with unexplained, widespread pain. People also would present with unexplained localized pain, such as low back pain or temporofacial pain. They'd get MRIs and what not and doctors could find no physiological explanation. Many people viewed these situations as having a psychodynamic origin, in other words the person was in fact obtaining some sort of reward from being sick or disabled, or acting out guilt or self-loathing, or just generally nuts.

Now we understand that people with otherwise unexplainable chronic pain are experiencing what's called Central Sensitization Syndrome (CSS). Pain signals (there's a fancy word for them, "nociceptive" which the blogger spell checker doesn't even recognize) do originate at the site where pain is perceived, but the sensation of pain is constructed in the brain, with maybe some intermediate processing in the spinal chord. The brain can also send signals back down to dampen nociception.

So what happens is that the systems in the brain that signal pain to your conscious awareness become hyperactive. If you close your eyes and just pay attention to your body right now, you will notice that you feel a bit of discomfort here and there. Maybe you have slightly achy joints, or your tuchy is a little uncomfortable on the chair, you have an itch, whatever. But it's minor and you weren't even paying attention to it. So, it shouldn't be hard to imagine that the circuits that process these sensations could get out of whack and continually scream "Pain!" at your frontal cortex.

Now that we have functional Magnetic Resonance Imaging, this has been confirmed. Researchers can see the circuits light up excessively in people with CSS. That doesn't help us know what to do about it, but at least we have an explanation. We also don't know why it happens. Often, people have a real injury that causes explainable acute pain, but after the injury heals, the pain persists. Somehow the circuit gets stuck in the open position, as it were. CSS also seems to be associated frequently with severe psychological trauma. But we don't have a good mechanistic explanation.

That said, if you tell people with CSS that there is in fact nothing wrong with the places where they feel pain, and the problem is in their brain, they generally don't like that answer. They hear you saying that the pain isn't real, that they are crazy, that they're faking it, that you aren't respecting their very real suffering which they perceive to be happening in their back and their joints or wherever.

Drugs don't usually help much. Long-term opioid therapy is generally a bad idea, I shouldn't have to tell you why. Anti-depressants and drugs that are used to treat seizures or neuropathy (pain caused by damage to peripheral nerves) are often prescribed, but only a small percentage of people really respond to them, and they have side effects. NSAIDs help only a little.

What people with CSS should do is basically not to let it get them down. Do what they call graded exercise -- a little bit more than is easy each day. Keep moving, keep up with your activities of daily living, have hope for the future, and really believe that there is nothing wrong with the parts of you that are hurting. It takes a long time, but often symptoms do ameliorate and even resolve. But if the pain beats you and you retreat from life and social contact, and stop moving, they won't.

So, how doctors and patients can communicate constructively in this situation, and form a therapeutic alliance that really works, is a big problem. Hopefully I'll be able to contribute.

Wednesday, November 12, 2014

Per Parillo, I never learned in my American history courses -- and I did take quite a bit -- that until the 19th Century, judges and government clerks and prosecutors and so on did not receive salaries. If you wanted your case heard, you had to pay the judge -- they worked on commission. Prosecutors were paid by the conviction. And if you wanted your homestead application or your deed processed, you had to pay the clerk, and he (always) could set his price. Really. Seems bizarre, but there was no idea of public service as a right of citizenship -- it was, by and large, for sale.

Per Goldstein, of course we didn't have universal public education for most of the country's history either, but as it began to come in, teachers had very low status. They gained more eventually, but now they are losing it again.

Balko discusses the militarization of the police, and the increasingly adversarial relationship between police and public, in recent decades. This kind of gets wedged into Knoczal's argument, because what he is really looking for are the civil forfeiture programs whereby police get to grab all kinds of cool stuff when they bust people, and the privatization of jails. We are also returning to the privatization of education, and of course rich people are buying judges and politicians.

The grand picture is that we are losing the consensus belief in national community that grew up in the 20th Century -- that all citizens have a stake in government and that government exists for the good of the people. Instead, whatever benefits government may offer are for sale to those who can afford them, while many services we used to depend on government to provide are no longer public goods at all. You get what you can pay for.

One would think this can only go so far before the civil order disintegrates. We shall see.

Tuesday, November 11, 2014

It's a very frustrating problem. As the old saying goes, "Don't confuse me with the facts, my mind's made up," and that is indeed how most people work most of the time.

If you don't already know about it, and you're into deep thoughts, you might want to bookmark Massimo Pigliucci's webzine Scientia Salon. He discusses a recent conference on denialism at Clark University here. We are currently in a very dangerous historical moment (my point, not his) in which a basic membership requirement for one of the two major parties in the world's most powerful nation is to believe a whole lot of important stuff that is not true.

The trap is that facts, reason, critical thinking -- none of these are of any use. In fact, research shows that when confronted with contrary facts, true believers just did in deeper.. An endless parade of experts can testify in front of James Inhofe's committee presenting every possible proof that humans are changing the planet's climate and that the consequences will be catastrophic, and the denial will just grow deeper.

So what is to be done? Obviously if I had the magic bullet we wouldn't be in this mess, but I will say that the key to the problem is more cultural than it is intellectual. We have to make saving the planet something the cool kids do, in essence. I largely credit the entertainment industry with the astonishing cultural transformation regarding attitudes toward homosexuality. The only people who are really going to establish the truths of evolution, environmental threats, macroeconomics (no, cutting rich people's taxes does not create jobs), and the fallacy of "free markets" are movie and TV producers, fiction writers, comedians, celebrity chefs, and such. Scientists should keep saying what they believe and keep answering questions, but the only ones who are going to accomplish very much are also entertainers -- Neil DeGrasse Tyson and his ilk. He pays as much attention to his costumes and his hairdo as he does to his words, and well he should.

They, and many other sober observers, find the reasoning of the DC Circuit panel in Halbig v. King absurd. It will be reversed by the full court, and it has been resoundingly rejected by all other federal courts. The Supreme Court does not need to hear the case. Why have they chosen to do so?

As all our readers presumably know, the ACA has three main components, all of which are essential for it to work. It requires insurance companies to cover everybody for the same price, with an adjustment for age, regardless of their current or former state of health. In other words, you can't be denied coverage or charged a fortune because of pre-existing conditions. (That's called guaranteed issue and community rating, BTW.) However, if you do that, there's a danger that people won't bother buying insurance until they get sick. You need those healthy people in the pool to keep it affordable for everybody. Hence the individual mandate. Again, however, not everybody can afford insurance, so you have subsidies for moderate income people. (We'll leave the Medicaid expansion aside for now.)

The literal language of the ACA says the subsidies are available to people who buy insurance through "exchanges established by the state." But Republican governors refused to establish exchanges in many states, so the federal government stepped in on their behalf. Elsewhere in the ACA this is clearly intended and the federally run exchanges are fully the equivalent of state-run exchanges. It's just slightly ambiguous language, but the intent of the statute is clear. Yet Halbig claims that people who get insurance through federally-run exchanges aren't eligible for the subsidies.

Krugman and Seigel both state, quite boldly, in their own ways, that if the court buys this absurdity it will prove that conservative jurisprudence is not about upholding the law, or any theory of law; it is purely political, adopting any form of sophistry in order to further the conservative political movement and the interests of the Republican party. That millions of people will lose their access to health care, and many of them will die, would apparently mean nothing to Scalia and Alito.

But what happens to the American polity if half of us are forced to conclude that the Supreme Court is a fundamentally illegitimate institution? I hope John Roberts is thinking about that.

In a nutshell, the incidence of thyroid cancer in South Korea has increased 15 times since the 1990s. Is it radiation? Water or air pollution? A plot by the north? Nope. It's an epidemic of overdiagnosis. The death rate from thyroid cancer hasn't gone up even a tiny little tick. What's happening is that the country offers free screening for other cancers -- cervical, colon, breast, liver -- and they'll throw in thyroid for 35 bucks. So people go for it. They find these tiny little tumors that were never going to cause trouble, remove the thyroid, and the people have to go on pills for the rest of their lives. They may suffer other complications. It turns out that about 1/3 of people die with these "cancers" without even knowing it. All of the increase -- 100% -- is overdiagnosis resulting in iatrogenic harm and wasted money.

This is appalling but it's happening in the U.S. too, to a lesser extent. We don't do screening but people sometimes happen to have ultrasounds or CT scans that include the neck and these meaningless phenomena are discovered. So you're told you have "cancer" and it's all bad from there on. As I have discussed before, something very similar happens with prostate "cancer" but the appallingness is less extreme because prostate cancers are somewhat more likely to cause trouble.

I do have one new point to make based on this atrocity. Doctors are always discovering non-existent diseases that need treatment. Sometimes the people have actual symptoms but the putative cause is not really there. Chronic low back pain is an example. A couple of decades ago the Agency for Healthcare Policy and Research reported that surgery commonly performed for chronic low back pain was useless. Orthopedic surgeons persuaded congress to eliminate the agency. (It has since been restored as the Agency for Healthcare Research and Quality.) This surgery is still performed, though less often than before.

There are many other examples but I won't belabor the point. When the doctors went on strike in Saskatchewan to protest single payer health care in 1962, the death rate went down. Just keep that in mind.

Wednesday, November 05, 2014

What can be very hard to see from the perch of someone with graduate training in public policy and a steady diet of journals of politics and public policy is that the great majority of people have a very limited grasp of public policy, and really for the most part don't understand how government affects their lives at all. Most Americans believe that the greatest share of the federal budget goes to foreign aid and "welfare," in which they do not include Medicare of Social Security. They think their taxes are too high even though their government services aren't good enough. They rationalize that because they think most of the money is either wasted or given to moochers. They are possessed of irrational fears while living in deep denial of real risks and problems.

These are the people who the Koch brothers are wooing with their billions in advertising. It's not that people actually want what Republicans want to give them. But if we are to do anything about this, we need more politicians who will tell the truth. The strategy of running away from president Obama instead of defending the achievements of the past six years was idiotic. If you pretend to be a Republican, there is no reason why people won't just vote for the real thing.

Monday, November 03, 2014

Another
prominent thinker who has given this considerable thought is James
Hughes, a sociologist from Trinity College in Connecticut. "We
are now entering the beginning of an era in which technology has
started to destroy employment faster than it creates it," he told io9.
"The advance of information technology, artificial intelligence and
robotics will eventually reduce the demand for all forms of human labor,
including those dependent on 'human skills' like empathy and
creativity."

He
offers the example of Expedia. The online program may not be as
creative at travel planning as an experienced travel agent, but it still
displaces travel agents because it's considerably cheaper and more
accessible. It's also an example of another impact of information
technology, that of cutting out the middle man.

"Eventually
3D printing and desktop manufacturing will cut out most of the work
between inventors and consumers," says Hughes. "Alongside growing
technological unemployment, we will also be living much longer, and will
need to figure out an equitable solution to the growing ratio of
retirees to workers and tax-payers.

At the same time, and probably related, is the much-discussed growing concentration of income and wealth among a smaller and smaller elite. If most people can't find work, two things will happen: a) nobody will be able to sell anything because consumers will mostly be broke and b) civilization will collapse. Otherwise, it won't be a problem.

The only solution -- an outcome Dvorsky thinks is inevitable -- is a Basic Income Guarantee. Everybody gets a check from the government, every month, that is enough to live on. Whether or not they choose to work, assuming they possibly can.

Sunday, November 02, 2014

Suppose my greatest fantasy is realized, and I invent teleportation. Several versions exist in sci-fi but let's say it's the kind where there are two capsules or chambers, and when you press the button the contents are swapped.

Distance doesn't matter, so I start by opening a service between Manhattan and LA. Ten people at a time, plus their luggage, can get into the machine at each end and badabing badaboom they're on opposite sides of the continent. Assuming they get on and off expeditiously, I can run it every sixty seconds. And it doesn't take a lot of energy. I can make an excellent profit charging 50 bucks a ticket. That's $1,000 a pop, 60 times an hour. I quickly have enough money to expand the service and create a dense network throughout the U.S., then go international, first to Mexico and Canada and then the whole world.

Apart from my own enrichment (not to be sneezed at), what are the consequences for humanity? It seems a great boon, not only because we save time and energy, and the world becomes more accessible and we all get to know each other and it ushers in a new era of peace and planetary cooperation (maybe, you can argue about that); but also because it creates an economic renaissance and stimulates a fabulous enlargement of prosperity.

Sadly, no. It will put the airlines, airports and aircraft manufacturers pretty much out of business, along with the intercity trains and buses. It will substantially reduce automobile sales. You still need them to get around town, but there will be many fewer long distance trips. All of this means massive unemployment. Instead of two or three pilots, six flight attendants, and time of baggage handlers, ticket sellers, air traffic controllers, airplane mechanics and what not, I employ a ticket seller, two schmoes to push the buttons, plus security and administrative resources, but again much less than it takes for air travel.

So what I have actually created is massive unemployment and the worst depression in history. With no evident way out for a long, long time. And this is a real problem we face today, without the fantasy. Technology that removes inefficiencies from the economy, and replaces human labor with technology, puts people out of work. So far, other forms of economic activity have come along so we haven't had massive, long-term structural unemployment, but there is no law of nature that says that has to happen. And maybe it won't this time.

There is plenty of argument going on right now about this question, but I think it's a real danger. And it has many possibly terrible consequences I won't take time to specify now. There is a solution -- income redistribution -- but our politics is dead set against that. I'll have further musings on these issues anon.